87-3034 - Laserfiche WebLink

Home Browse Search

r APPLICATION FOR PERMIT SAN 50 QUIN LOCAL HEALTH DISTRICT ((�J ` 1601 E. HAZE T ON AVE., STOCKTON, CA ' Telephone {209}.466-6781 . PERMIT EXPIRES TYEAR FROM DATE ISSUED 4 (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with all Joaquin County Ordinance No.549 for sewage ort No. 1862 fort well/!pump and the Rules ands Regulations of the San Joaquin -1 1Local Health District �/•� h►j IC —e�JT o� Lf 1 Y��1•ff..� dAV0 7A�0 Job Addres A Cit Lot Sizevzw PM Owner's Name (idress A Phone a r, kA -- 4 �1 Contractor %Addres � License n01 9 �$ PhoneaC� TYPE OF WELL/PUMP: NEW WELL ' WELL REPLACEMENT O'l;* . C".DESTRUCTION ❑4 - �• e PUMP INSTALLATION q! ' SYSTEM REPAIR ❑ tiOTHER ❑ + DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE �� ,N FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial men Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing, Specifications �d ('l Public 171 Other Cl Delta Depth of Grout Seal T e of Grout�� I I Ifrigation Approx, Depth I 1hastetn Surface Seal Installed by - i Repair Work Done 13Type of Pump H.P. - State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ['I REPAIR/ADDITION I i DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth r r SEPTIC TANK ❑ Type/Mfg Capacity No _Compartments 3 E PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size t FILTER BED ❑ Distance.to,nearest: Well Foundation Property Line SEEPAGE PITS V] Depth Size Number SUMPS CI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. i Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall nots employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." v j1 The applicant mupt call for all required inspections. Complete drawing on reverse side. I Age Signed-X.. Title: Rate: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspect' y r Date Final Inspection by Date `® Additional Comments: ❑ Stk 466.6781 ❑ Log 369-3621 ❑ Manteca 823-1104 ❑ Tracy 835-6385 Q Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,`Stk., CA 95201 t FEE AM NT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH P + EH 13-24(REV.r/N 5) 04 A� yr.r 2 1 EH 14-26